Mary Anne Mercer

Developing competencies for a graduate school curriculum in international health.

which does not have a school of public health (SPH) The University of Washington School of Public Health (UW SPH) in Seattle, Washington, has met this chal-lenge by expanding and reorganizing its international public health teaching. We have established competen -cies for our global health MPH scholars, with a focus on addressing large public health problems with a social justice perspective.The emergence of the global health concept over the last decade reflects heightened awareness of accelerating globalization processes that challenge the traditionally drawn boundaries between the interna-tional and domestic health professional worlds. While the precise definition of global health continues to be contested, it is widely agreed that increased global flows of resources, information, people, and infectious diseases, together with growing global inequality, have created new public health problems that require fresh and innovative approaches. With this recognition has come a spate of new global health centers, departments, institutes, and programs in American and European universities that seek to redefine approaches to public health and recalibrate training to new global health realities for the next generation of health researchers and practitioners. While the urgency for such redefined training is apparent, there is little in the current public health literature that attempts to identify just what this training should include. In spite of new global health program proliferation, core professional global health competencies have yet to be defined, and no consensus for development of appropriate curricula has emerged in the public health field. The recent creation of a new Department of Global Health (DGH) at UW has presented cur-riculum planners, charged with developing new MPH, doctor of philosophy (PhD), and doctor of medicine programs, with these immediate challenges. This article describes the consensus-building process conducted by the DGH curriculum committee over a one-year period in which global health competencies were identified and curriculum needs redefined. While debates about the meaning and scope of global health will continue, basic guidelines for new kinds of training are urgently needed to prepare health workers for the rapidly chang-ing environment they will soon confront.Through this recently established DGH (which has received much of its new funding through an endowed grant from the Bill and Melinda Gates Foundation), UW is poised to rapidly expand its international health student enrollment, course offerings, and degree programs. Other prominent universities have launched similar efforts in just the last two years. In 2006, Duke University in Durham, North Carolina, to date, launched a new Global Health Institute, which started its education program with an undergraduate certificate. The Johns Hopkins University in Baltimore, Maryland, launched a Center for Global Health, bringing together its SPHs, medicine, and nursing schools in a collaborative effort. In addition, other schools such as The George Washington University in Washington, DC, have recently started offering MPH degrees in global health.As UW prepared to launch its DGH—a collaboration between the SPH and the school of medicine—the curriculum committee of the existing international health program embarked on a complete review of UW’s current course offerings in anticipation of growth and expansion. We found very little guidance for this effort in the public health literature. Patrick reported major gaps in public health training, along with the implication of inadequate coursework in SPHs and in medical schools.

Intermittent preventive treatment of malaria during pregnancy in central Mozambique.

PROBLEM New WHO strategies for control of malaria in pregnancy (MiP) recommend intermittent preventive treatment (IPTp), bednet use and improved case management. APPROACH A pilot MiP programme in Mozambique was designed to determine requirements for scale-up. LOCAL SETTING The Ministry of Health worked with a nongovernmental organization and an academic institution to establish and monitor a pilot programme in two impoverished malaria-endemic districts. RELEVANT CHANGES Implementing the pilot programme required provision of additional sulfadoxine-pyrimethamine (SP), materials for directly observed SP administration, bednets and a modified antenatal card. National-level formulary restrictions on SP needed to be waived. The original protocol required modification because imprecision in estimation of gestational age led to missed SP doses. Multiple incompatibilities with other health initiatives (including programmes for control of syphilis, anaemia and HIV) were discovered and overcome. Key outputs and impacts were measured; 92.5% of 7911 women received at least 1 dose of SP, with the mean number of SP doses received being 2.2. At the second antenatal visit, 13.5% of women used bednets. In subgroups (1167 for laboratory analyses; 2600 births), SP use was significantly associated with higher haemoglobin levels (10.9 g/dL if 3 doses, 10.3 if none), less malaria parasitaemia (prevalence 7.5% if 3 doses, 39.3% if none), and fewer low-birth-weight infants (7.3% if 3 doses, 12.5% if none). LESSONS LEARNED National-level scale-up will require attention to staffing, supplies, bednet availability, drug policy, gestational-age estimation and harmonization of vertical initiatives.

East Timor in Transition: Health and Health Care

East Timor was liberated from 400 years of conquest and exploitation in an armed struggle that ended, in September 1999, in a conflagration that destroyed its social and physical infrastructures. For two years the territory has been under United Nations administration. Political conditions remain unstable as the result of many intrinsic and external factors. Its economy continues to depend upon infusions of funds from multilateral, bilateral, and private sources. Efforts by expatriates to introduce Euro-American cultural and technical models have been applied to the factors that determine health, with modest results. East Timor expects to be totally independent of foreign control early in 2002. Its future health will depend upon continuing collaboration between international and local leadership in evolving effective government, economy, and health services designed, managed, and executed by Timorese.

Implementation and progress of an inclusive primary health care model in Guatemala: coverage, quality, and utilization

OBJECTIVE To describe a primary health care model designed specifically for Guatemala that has been implemented in two demonstration sites since 2004 and present results of a process evaluation of utilization, service coverage, and quality of care from 2005 to 2009. METHODS Coverage, utilization, and quality were assessed by using an automated database linking census and clinical records and were reported over time. Key maternal and child health coverage measures were compared with national-level measures. RESULTS The postnatal coverage achieved by the Modelo Incluyente de Salud of nearly 100.0% at both sites contrasts with the national average of 25.6%. Vaccination coverage for children aged 12-23 months in the Modelo Incluyente de Salud reached 95.6% at site 1 (Bocacosta, Sololá) and 92.7% at site 2 (San Juan Ostuncalco), compared with the national average of 71.2%. Adherence to national treatment guidelines increased significantly at both sites with a marked increase between 2006 and 2007. Utilization increased significantly at both sites, with only 7.5% of families at site 1 and 11.2% of families at site 2 not using services by the end of the 5-year period. CONCLUSIONS Coverage, quality of care, and utilization measures increased significantly during the 5-year period when the service delivery model was implemented. This finding suggests a strong possibility that the model may have a benefit for health outcomes as well as for process measures. The Modelo Incluyente de Salud will be financially sustained by the Ministry of Health and extended to at least three additional sites. The model provides important lessons for primary care programs internationally.

What does high and low have to do with it? Performance classification to identify health system factors associated with effective prevention of mother-to-child transmission of HIV delivery in Mozambique

Efforts to implement and take to scale highly efficacious, low‐cost interventions to prevent mother‐to‐child HIV transmission (pMTCT) have been a cornerstone of reproductive health services in sub‐Saharan Africa for over a decade. Yet efforts to increase access and utilization of these services remain far from optimal. This study developed and applied an approach to systematically classify pMTCT performance to identify modifiable health system factors associated with pMTCT performance which may be replicated in other pMTCT systems.

Immunization campaigns and political agendas: retrospective from Ecuador and El Salvador.

Since the mid-1980s international donors have promoted vertical, campaign-based strategies to help improve immunization coverage in poor countries. National immunization days (NIDs) are currently in vogue and are prominent in the worldwide polio eradication efforts. In spite of their widespread use, campaigns that include NIDs have not been well evaluated for their effects on coverage, reduction in vaccine-preventable diseases, or effects on the health system. An assessment of the results of two such campaigns implemented in Ecuador and El Salvador shows limited impact on short-term coverage and questionable effects on long-term coverage and disease incidence. Although NIDs may have substantial short-term political benefits, the vertical approach can undermine provision of routine services by ministries of health and may be counterproductive in the long-term.

The prevention of mother-to-child transmission of HIV cascade analysis tool: supporting health managers to improve facility-level service delivery

BackgroundThe objective of the prevention of Mother-to-Child Transmission (pMTCT) cascade analysis tool is to provide frontline health managers at the facility level with the means to rapidly, independently and quantitatively track patient flows through the pMTCT cascade, and readily identify priority areas for clinic-level improvement interventions. Over a period of six months, five experienced maternal-child health managers and researchers iteratively adapted and tested this systems analysis tool for pMTCT services. They prioritized components of the pMTCT cascade for inclusion, disseminated multiple versions to 27 health managers and piloted it in five facilities. Process mapping techniques were used to chart PMTCT cascade steps in these five facilities, to document antenatal care attendance, HIV testing and counseling, provision of prophylactic anti-retrovirals, safe delivery, safe infant feeding, infant follow-up including HIV testing, and family planning, in order to obtain site-specific knowledge of service delivery.ResultsSeven pMTCT cascade steps were included in the Excel-based final tool. Prevalence calculations were incorporated as sub-headings under relevant steps. Cells not requiring data inputs were locked, wording was simplified and stepwise drop-offs and maximization functions were included at key steps along the cascade. While the drop off function allows health workers to rapidly assess how many patients were lost at each step, the maximization function details the additional people served if only one step improves to 100% capacity while others stay constant.ConclusionsOur experience suggests that adaptation of a cascade analysis tool for facility-level pMTCT services is feasible and appropriate as a starting point for discussions of where to implement improvement strategies. The resulting tool facilitates the engagement of frontline health workers and managers who fill out, interpret, apply the tool, and then follow up with quality improvement activities. Research on adoption, interpretation, and sustainability of this pMTCT cascade analysis tool by frontline health managers is needed.Trial RegistrationClinicalTrials.gov NCT02023658, December 9, 2013

The Role of International NGOs in Health Systems Strengthening: The Case of Timor-Leste:

Achieving the United Nations Millennium Development Goals for health will require that programs supporting health in developing countries focus on strengthening national health care systems. However, the dominant neoliberal model of development mandates reduced public spending on health and other social services, often resulting in increased funding for nongovernmental organizations (NGOs) at the expense of support for government systems. East Timor, later Timor-Leste, is an example of a post-crisis country where international NGO efforts were initially critical to providing relief efforts to a traumatized population. Those groups were not prepared to help develop and support a standardized Timorese national health plan, however, and the cost of their support was unsustainable in the long term. In response, local authorities designed and implemented a post-crisis NGO phase-over plan that addressed risks to service disruption and monitored the process. Since then, some NGOs have worked collaboratively with the Ministry of Health to support specific efforts and initiatives under a framework provided by the ministry. Timor-Leste has shown that ministries of health can facilitate an effective transition of NGO support from crisis to development if they are allowed to plan and manage the process.

The Cuban Response to the Ebola Epidemic in West Africa: Lessons in Solidarity

In December 2013 the first case of Ebola appeared in Guinea. In September 2014 the United Nations (UN) and its specialized agency the World Health Organization (WHO) issued a call for medical collaboration in response to the medical crisis and social disaster caused by the Ebola virus epidemic in West Africa. Cuban authorities responded immediately to the call by offering specialized help for the epidemic, in collaboration with WHO. A group of 256 Cuban doctors, nurses and other health professionals provided direct care during the Ebola epidemic in Sierra Leone, Liberia and Equatorial Guinea from October 2014 to April 2015. This paper explains the main features of the Cuban health system, describes the development of Cubas international medical cooperation approach, and highlights the work done by Cuban health collaborators in addressing the damage caused by the Ebola epidemic. Information used includes reports and documents of the Ministry of Public Health of Cuba, reports of WHO and PAHO, and articles published in scientific journals and newspaper articles. The response of the Cuban medical teams to the Ebola epidemic in West Africa is only one example of the Cuban efforts to strengthening health care provision in areas of need throughout the world.

Implementation and progress of an inclusive primary health care model in Guatemala

OBJECTIVE To describe a primary health care model designed specifically for Guatemala that has been implemented in two demonstration sites since 2004 and present results of a process evaluation of utilization, service coverage, and quality of care from 2005 to 2009. METHODS Coverage, utilization, and quality were assessed by using an automated database linking census and clinical records and were reported over time. Key maternal and child health coverage measures were compared with national-level measures. RESULTS The postnatal coverage achieved by the Modelo Incluyente de Salud of nearly 100.0% at both sites contrasts with the national average of 25.6%. Vaccination coverage for children aged 12-23 months in the Modelo Incluyente de Salud reached 95.6% at site 1 (Bocacosta, Sololá) and 92.7% at site 2 (San Juan Ostuncalco), compared with the national average of 71.2%. Adherence to national treatment guidelines increased significantly at both sites with a marked increase between 2006 and 2007. Utilization increased significantly at both sites, with only 7.5% of families at site 1 and 11.2% of families at site 2 not using services by the end of the 5-year period. CONCLUSIONS Coverage, quality of care, and utilization measures increased significantly during the 5-year period when the service delivery model was implemented. This finding suggests a strong possibility that the model may have a benefit for health outcomes as well as for process measures. The Modelo Incluyente de Salud will be financially sustained by the Ministry of Health and extended to at least three additional sites. The model provides important lessons for primary care programs internationally.